In 2007, the American College of Physicians, the. Patient-Centered Communication in Primary Care: Physician and Patient Gender and Gender Concordance

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1 JOURNAL OF WOMEN S HEALTH Volume 18, Number 4, 2009 ª Mary Ann Liebert, Inc. DOI: =jwh Patient-Centered Communication in Primary Care: Physician and Patient Gender and Gender Concordance Klea D. Bertakis, M.D., M.P.H., 1 Peter Franks, M.D., 1 and Ronald M. Epstein, M.D. 2 Abstract Background: Physicians use of patient-centered communication (PCC) affects important outcomes of care. Although there is evidence that both patient and physician gender affect the process of care, there is limited information about their impact on PCC. Our objective was to investigate the influence of patient and physician gender, as well as gender concordance between patient and physician, on the patient centeredness of primary care visits. Methods: Participating primary care physicians (100 family physicians and internists) with clinical practices in the Rochester, New York area, had two unannounced covertly audiorecorded standardized patients visits. Encounters were analyzed using the Measure of Patient-Centered Communication ( MPCC), which measures three aspects of physician communication: Component 1 (Exploring both the disease and illness experience), Component 2 (Understanding the whole person), and Component 3 (Finding common ground). Results: Compared with male patients, females had interactions characterized by greater PCC (total and Component 2 scores). Whereas female physicians exhibited higher Component 1 scores, male physicians had higher Component 2 scores, and gender-concordant visits also exhibited higher Component 2 scores. However, there were no significant differences in total MPCC scores for encounters of female vs. male physicians or for genderconcordant compared with discordant patient-physician dyads. Conclusions: These findings add further evidence that patient gender can affect the interactions between physicians and patients. More research is needed to understand why male patients are less likely to have medical encounters in which their physicians employ a patient-centered practice style. Introduction In 2007, the American College of Physicians, the American Academy of Family Physicians, and the American Osteopathic Association, representing 333,000 physicians, developed joint principles to describe characteristics of the patient-centered medical home (PC-MH). The PC-MH is a comprehensive primary care approach that facilitates partnerships between patients of all ages, their personal physicians, and when appropriate, the patient s family. 1 This recent development has brought renewed attention to patient-centered communication (PCC) in primary care settings. Over the last 40 years, an extensive body of literature has supported the patient-centered approach to medical care. The term patient-centered is widely used and has as its basis that an understanding of the patients unique constellation of concerns and subjective experience of illness is as fundamental to healthcare as physician-defined disease categories. Patient-centered care may be most easily understood for what it is not, namely, disease centered (biomedical), technology centered, physician centered, or hospital centered. 2 The patient-centered approach is a complex and multifaceted construct, 3 and there is general consensus that it differs from the traditional biomedical approach in relationship to five key dimensions, each focusing on a specific aspect of the physician-patient relationship: understanding the patient s illness within a broader biopsychosocial context, appreciating the patient s experience of illness, advocating an egalitarian doctor-patient relationship, creating a therapeutic alliance, 1 Department of Family and Community Medicine and Center for Healthcare Policy and Research, University of California, Davis, Sacramento, California. 2 Departments of Family Medicine, Psychiatry and Oncology, Rochester Center to Improve Communication in Health Care, University of Rochester School of Medicine and Dentistry, Rochester, New York. 539

2 540 BERTAKIS ET AL. and acknowledging the influence of the doctor s personal qualities on the medical interaction. 4 Communication is a central element of patient-centered care. An operational definition of PCC should include six functions: the fostering healing relationships, exchanging information, responding to emotions, managing uncertainty, making decisions, and enabling patient self-management. 5 Despite the lack of a uniform definition of PCC, there are several scales developed to measure it. The main two methodological approaches are self-reported (by both patient and physician) assessments of the patient centeredness of the medical encounter and direct observation of the clinical encounter (with real or standardized patients) to evaluate the process of care. These generally measure observable sets of communication behaviors: (1) eliciting and understanding the patient s perspective concerns, ideas, expectations, needs, feelings, and functioning, (2) understanding the patient within his or her unique psychosocial context, (3) reaching a shared understanding of the problem and its treatment with the patient that is concordant with the patient s values, and (4) creating a partnership in which patients can share in decision making, power, and responsibility. 4 Because PCC is multifaceted, these components may not be highly correlated with one another, even within a single coding system. 2,3 Physicians practice styles vary, but on the whole, most provide patients with care characterized by at least some observable PCC behaviors. One study reported the average patient-centered score for primary care visits to be 50.7 (SD 17.9, range 8 93), on a scale of It would seem intuitive that patients would prefer patient-centered care from their physicians, and it has been reported that 69% of the patient participants prefer a patient-centered style. 7 These patients tend to be younger, more educated, white, and female and have a higher income. 7 9 Indeed, it has been shown that a biomedically or technically focused visit, the antithesis of one that is patient centered, results in the lowest patient satisfaction. 9,10 Although patients seem to prefer a patient-centered approach, data about the relationship between patient-centered care and improved patient health have been inconsistent There is, however, preliminary evidence for an association between PCC and the use of healthcare resources. Physicians having visits characterized by the highest scores on the Measure of Patient-Centered Communication (MPCC) have the lowest expenses for diagnostic testing, as well as total expenditures (tests, ambulatory, and hospital care). 15 The gender of the patient and the physician can also have an impact on the process of medical care and its outcomes. Male and female physicians have been found to differ in the way they communicate during medical encounters. Female primary care physicians engage in more partnership building, information sharing, discussion of psychosocial topics, and encouragement of patient participation in their interactions with patients These behaviors are related to those observed in PCC. Male physicians, however, tend to devote more time to technical practice behaviors, such as history taking. A number of studies have noted differences in the physician-patient interaction associated with patient gender. Female patients ask more questions, get more information, receive more counseling and preventive services, and have more participatory visits than do male patients Gender may affect the physician-patient interaction in a variety of ways, including sex roles and attitudes, culturally mediated differences in use of language, differences in patient expectations of male compared with female physicians, and differences in status levels between patient and physician in opposite-sex vs. same-sex physician-patient dyads. In order to fully assess the effects of physician and patient gender, gender concordance and discordance must be examined with samesex and opposite-sex dyads. 23 There is evidence for the influence of physician-patient concordance on patient care. 21,24 27 Gender concordance has been associated with greater patient trust in their physician. 25 Gender-congruent visits are also longer than gender-incongruent visits, with female physicians having significantly longer visits with their female patients than any other physician-patient dyad. 26,27 This finding may be associated with the performance of gender-specific(breastandpelvic) physicalexaminations. With regard to the communication differences in various physicianpatient gender dyads, male patients seeing male physicians have been observed to have the least participatory visits compared with male patients seeing female physicians, as well as female patients seeing either female or male physicians. 21 We used data from a study of physician communication in primary care employing standardized patients 15 to examine the relationships among the use of PCC, physician and patient gender, and gender concordance. Use of standardized patients (SPs) (compared with encounters using real patients) has at least two advantages. First, we are able to standardize the content and severity of the presenting complaint. Second, we avoid the problem of patient-physician dyads being selfselected on the basis of gender or other mutual preferences. Based on the literature, it was hypothesized that female physicians would have more patient-centered practice style behaviors than male physicians and that female patients would be more likely to have visits incorporating PCC. Third, it was expected that patient-centered medical care would be seen more often when there was gender concordance between physician and patient. Materials and Methods Physician sample We identified 594 primary care physicians in active clinical practice within 45 minutes drive of Rochester, New York, belonging to a large managed care organization (MCO) serving the eight-county Rochester region (population 1.1 million). We oversampled family physicians to allow for comparisons between family physicians and internists. A maximum of two physicians per practice were recruited to avoid clustering effects and minimize physician detection of SPs. There remained 297 eligible physicians who were recruited by twelve physician recruiters in random order until a total of 100 physicians were recruited. Physicians gave informed consent to participate in a study of patient care and outcomes. They agreed to have two unannounced covertly audiorecorded SP visits over a period of 12 months. Physicians were reimbursed $100 for each SP visit; $100 was also provided to the office staff for their assistance. The study received Institutional Review Board approval. Standardized patient encounter data We developed SP roles to provide physicians with identical clinical scenarios (each patient presenting an identical set of

3 PATIENT-CENTERED COMMUNICATION AND GENDER 541 concerns, minimizing bias due to real patient differences and patient selection of physician) and to avoid logistic problems with real patients. For example, SPs can be introduced into the practice incognito, whereas in real patient encounters, such blinding is impossible; physicians and patients may modify their behavior when they know they are being observed. A physician community advisory panel suggested that the use of more than two SPs would likely compromise physician recruitment. During , each physician had visits from two SPs, portraying one of two roles. The two roles were selected to contrast physicians responses to patients with straightforward symptoms with those who present ambiguous or medically unexplained symptoms. The heartburn role involved nocturnal chest pain exacerbated by food and partially relieved by antacids, with minimal emotional distress. The ambiguous symptoms role involved multiple symptoms, poorly characterized chest pain, and moderate emotional distress characteristic of multisomatoform disorder. 28 In pilot testing, the roles were calibrated to avoid prompting referral to an emergency department or administration of medications in the physician s office. Five middle-aged, nonobese, white SPs (two men, three women) were used in the study. The patients were middle-class and were given dummy private insurance cards. Each physician saw one male and one female SP, and one of each role (two female SPs were needed for the gastroesophageal reflux disease [GERD] role, as one SP could not complete all visits in the study; each SP made at least 25 visits). The first SP visit was randomized by illness condition and gender. The SP trainer reviewed all audiotaped SP-physician encounters and rated SP performance on a detailed checklist; we set a criterion score of 95% for inclusion of the data in the study. Our mean scores were 97% 98%, and none of the visits were excluded. Furthermore, we asked raters blinded to the study hypotheses to try to determine from the recordings if the physician had detected the encounter as an SP visit, and they were unable to do so. Observational coding system (MPCC) Encounters were recorded and analyzed using the MPCC observational coding system. 29 The MPCC has demonstrated adequate reliability (interrater reliability reported as ) and validity. It measures three distinct but related aspects (or components) of physician communication and is unique in that it is theoretically linked to a model of PCC. For Component 1 (Exploring both the disease and the illness experience), the coder notes patient statements about symptoms, ideas, expectations, feelings, and the effect of the symptoms on functioning. Component 2 (Understanding the whole person) uses a similar method to measure the degree to which the physician explores the patient s family, social network, job, and interests. Component 3 (Finding common ground) measures the degree to which the physician explains and involves the patient in discussions about the nature of the problem and the management plan. This includes providing clear explanations and encouraging patients to ask questions. For example, physicians who ask questions, such as: What do you think of that? or Do you have any questions? after explaining a diagnosis received higher scores on Component 3. Scoring of the physician s response to each concern raised by the patient is based on whether it is coded as a nonresponse (0 points), preliminary exploration (2 points), or preliminary and further exploration (3 points). Validation of that concern adds an additional 2 points, for a maximum of 5 points and a minimum of 0. A cutoff of a preliminary exploration, further exploration, or validation results in a loss of 2 points. An example of further exploration might be when a physician asks a follow-up question when a patient expresses fear or anxiety, and validation would occur if the physician says, It s only natural to feel that way. The score for each component is the sum of ratings of specific behaviors divided by the number of behaviors rated. The score is rescaled (from 0 to 5) to 0 to 1. The total MPCC score represents the mean of the three component scores. Scores range from 0 (not patient centered) to 1 (most patient centered). We trained two female coders to score the recordings using the MPCC; 10% of recordings were dual-coded. In the present study, intraclass correlation coefficients for the three components were 0.67, 0.89, and 0.43, respectively. Our reliability data, as well as means and standard deviations (SDs) of the scores, were virtually identical to those reported by the developers. The correlation of MPCC scores between the two cases was 0.39 ( p ¼ ), suggesting a significant physician style effect. Because of logistic problems, we were able to obtain usable recordings on only 96 of the 100 enrolled physicians. Physician variables Toward the end of their involvement in the study, physicians completed a questionnaire, including demographics (age and gender), practice characteristics (specialty, number of partners [solo vs. two or more], and location [rural, suburban, or urban]). Analyses Data were analyzed using STATA (version 10.0, StataCorp, College Station, TX). The main analyses implemented generalized mixed models to account for the nesting of the two observations within each physician. 30 Such an approach also allowed us to examine the physician intraclass correlation (rho) between the two cases seen by each physician. Four linear regression models were executed, with the dependent variables being total MPCC score and the three component scores. The key independent variables were physician and SP gender and their interaction. Analyses also adjusted for case (ambiguous vs. not), physician age, specialty (family medicine vs. internal medicine), solo practice (vs. not), and practice location (rural, suburban vs. urban as reference). To facilitate interpretation, dependent variables were standardized by dividing scores by their SD; thus, parameter estimates represent effect sizes. Cohen 31 has defined effect sizes in the range of 0.2 as small, 0.5 as medium, and 0.8 as large. 31 Results Of the 297 physicians identified for recruitment, 109 (37%) refused to participate, and 14 were ineligible. Of the 100 physicians enrolled, 93 completed both SP visits, 7 completed only one visit, and none withdrew from the study. Owing to recording problems, the MPCC was able to be coded on 189 encounters. The characteristics of the key variables are shown in Table 1. In addition, Table 2 displays unadjusted mean MPCC total and component scores by physician and patient gender.

4 542 BERTAKIS ET AL. Table 1. Distribution of Key Study Characteristics Physician Female (%) 33 Family physicians (%) 48 Age, years, mean (SD, a range) 45.2 (8.3, 33 69) Solo (%) 24 Location Rural (%) 32 Suburban (%) 12.5 Urban (%) 55 MPCC score b Total, mean (SD, range) 0.50 (0.08, ) Component 1, mean (SD, range) 0.45 (0.09, ) Component 2, mean (SD, range) 0.50 (0.19, 0 1) Component 3, mean (SD, range) 0.54 (0.12, ) a SD, standard deviation. b MPCC and its component scores are scaled 0 1. There were no significant differences by physician gender in the MPCC scores for female SPs. For male SPs, the Component 1 score was higher in visits with female MDs, whereas the Component 2 score was higher in visits with male MDs. Table 3 shows the adjusted MPCC total and component scores by physician and patient gender. For the total score, there was a significant main effect for SP gender; encounters with female SPs were associated with higher MPCC scores. Neither physician gender effects nor the interaction between physician and SP effects were statistically significant. For Component 1, there was a significant main effect for physician gender; encounters with female physicians were associated with higher MPCC scores. SP gender effects and the interaction between physician and SP effects were not statistically significant. Component 1 scores were significantly lower for the ambiguous case (compared with the unambiguous case). For Component 2, there was a significant main effect for physician gender; encounters with female physicians were associated with lower scores. There was also a significant main effect for SP gender; encounters with female SPs were associated with higher scores. There was also a significant physician-sp gender interaction effect; gender-concordant visits exhibited higher scores. For Component 3, none of physician gender, SP gender, or their interaction effects were statistically significant. The total score analysis intraclass correlation (ICC) for the two cases was 0.44 (95% CI 0.28, 0.62). The Component 1 score Table 2. Mean Measure of Patient-Centered Care (MPCC) and Component Scores, by Patient and Physician Gender MPCC score (SD) Male M.D. Female SP a Female M.D. Male M.D. Male SP Female M.D. Total MPCC b 0.50 (0.09) 0.52 (0.05) 0.49 (0.07) 0.48 (0.12) Component (0.10) 0.45 (0.07) 0.44 (0.09) 0.49 (0.08) Component (0.20) 0.53 (0.08) 0.53 (0.16) 0.42 (0.28) Component (0.11) 0.56 (0.11) 0.51 (0.12) 0.52 (0.11) a SP, standardized patient; SD, standard deviation. b MPCC and its component scores are scaled 0 1. Table 3. Adjusted Measure of Patient-Centered Care (MPCC) and Component Scores (95% CI) by Patient and Physician Gender Parameter estimate (95% CI) Total MPCC a Female M.D ( 0.64, 0.34) Female SP b 0.50 (0.05, 0.95) M.D.*SP c 0.32 ( 0.19, 0.83) Ambiguous case d 0.03 ( 0.18, 0.25) Component 1 Female M.D (0.14, 1.09) Female SP 0.48 ( 1.01, 0.04) M.D.*SP 0.53 ( 1.13, 0.07) Ambiguous case 0.31 ( 0.56, 0.05) Component 2 Female M.D ( 1.05, 0.08) Female SP 0.66 (0.18, 1.14) M.D.*SP 0.79 (0.24, 1.33) Ambiguous case 0.17 ( 0.06, 0.40) Component 3 Female M.D ( 0.38, 0.57) Female SP 0.36 ( 0.18, 0.90) M.D.*SP 0.19 ( 0.80, 0.43) Ambiguous case 0.04 ( 0.22, 0.29) a MPCC and component scores and parameter estimate are standardized (score=sd). SP, standardized patient. c M.D.*SP refers to the interaction between physician and SP gender. d Ambiguous case refers to the effect for the ambiguous case (vs. unambiguous case). Analyses also adjusted for physician age, location (specialty family medicine or internal medicine), location (rural, suburban, or urban), and group size (solo or not). analysis ICC was 0.20 (95% CI 0.06, 0.45). The Component 2 score analysis ICC was 0.32 (95% CI 0.15, 0.53) and the Component 3 score analysis ICC was 0.19 (95% CI 0.06, 0.44). We also conducted a set of analyses separately for each case. Using the method of Clogg et al., 32 we examined whether the parameter estimates for each case were different. For each set of comparisons (total MPCC and each of the three components), there was no evidence of statistically significant differences between the parameter estimates ( p > 0.1). Discussion Ours is the first study, using a reliable and validated observational instrument (the MPCC), to examine the role of both physician and patient gender and their concordance in PCC. We found some evidence that encounters with female SPs had higher PCC overall and for Component 2. There was no overall physician gender effect on PCC reflecting opposite effects for Component 1 (higher for female physicians) and Component 2 (lower for female physicians). Gender concordance was associated with higher Component 2 scores, but there was no overall effect. Component 3 exhibited no genderrelated effects. The significant ICCs and absence of statistically significant differences between the two cases suggested that physicians exhibited a consistent style in response to both cases. Our first hypothesis, that female physicians, compared with their male counterparts, would have a greater tendency to incorporate patient-centeredness in their interactions with p

5 PATIENT-CENTERED COMMUNICATION AND GENDER 543 patients, was correct only for Component 1. On the other hand, female physicians were found to be less likely to employ a Component 2 approach with their patients. Reflecting the opposite physician gender effects on Components 1 and 2, and lack of effect on Component 3, there was no overall effect of physician gender on the total MPCC score. Looking more closely at the results for Component 2, the lower score for female physicians appears largely to reflect a lower score for female physician-male patient dyads. We speculate that given traditional male-female relationship dynamics, the female physician-male patient combination may be less comfortable for both partners than gender-concordant and male physician-female patient combinations. That discomfort may translate into less exploration into the patient s social and family context. (Component 2). These findings contrast with reports suggesting that female physicians engage in more communication that can be considered patient centered. 18,19 However, the studies included in the meta-analyses reported did not specifically use the MPCC. This highlights the theoretical and practical challenges for measuring and comparing PCC during medical visits. 3 The contrasting physician gender effects observed for Components 1 and 2 were unexpected and are not easy to explain. Component 1 seeks to measure the extent to which the physician explores how the illness affects the patient as a person. The score is higher for those physicians who validate their patient s experience of the illness, a core element of PCC. Component 2 seeks to measure the extent to which the physician inquires about the whole person; scoring is based on the extent to which the physician asks about family and social context. It is not clear from our analyses whether the higher Component 2 scores represent an organized inquiry into social determinants of health and well-being or more superficial social chat. Given the paradoxical findings, further exploration of this issue is warranted. It is possible that the use of SPs rather than real patients contributed to the lack of a net effect of physician gender on total MPCC scores. For example, the standardized scripted format used by the SPs may have blunted gender-specific patient effects and, in turn, gender-specific responses by physicians. Prior studies investigating the relationship between physician gender and patient centeredness have used real patients. As noted in the Introduction, mutual selection between patients and physicians is likely affected by physician gender. In general, female patients prefer female physicians, and female physicians disproportionately care for more female patients. 27 Given that encounters with female patients are characterized by more patient centeredness, the preponderance of female patients (specifically selecting female physicians) among female physicians may result in an apparent association between physician gender and patient centeredness. Our use of SPs may have avoided this potential bias. Our hypothesis regarding female patients was confirmed. Compared with male patients, female SPs had interactions with their physician characterized by greater PCC (total MPCC), an effect also evident for Component 2. The effects observed for patient gender were the most robust findings among all those examined. Female gender may influence patient-physician communication in several ways. Physicians may have social expectations that female patients place greater value on or feel more comfortable with discussions of personal information about family and job and may interpret the similar nonverbal signals differently based on patient gender. These factors may be self-fulfilling prophecies if physicians, therefore, elicit patients personal and contextual information to a greater degree. Correspondingly, the female SPs may have reflected this same social expectation through greater assertiveness or responsiveness to physicians inquiries verbal or nonverbal. Female patients are generally more verbally assertive and participatory. At least one study documents that more verbally assertive patients induce PCC behaviors in their physicians (e.g., more information, more active listening). 36 Although this study employed SPs who portrayed their roles consistently, it is possible that despite standardization, female SPs may have been more assertive, and physician communication behaviors may reflect the expression of greater patient assertiveness. Regarding the influence of physician-patient gender concordance on communication (our final hypothesis), we found that gender-concordant visits exhibited higher Component 2 scores compared with gender-discordant visits. Perhaps same-sex dyads find social chat (which would result in higher Component 2 scores) to be more comfortable. It should be noted that although higher Component 2 scores can be achieved by engaging in a greater number of superficial inquiries about psychosocial issues (social chat) and fewer cutoffs of these topics, the highest scores are achieved by a deeper exploration of patients substantial concerns about psychosocial aspects or determinants of health and well-being and expressing empathy or validation. However, there was no significant association between gender concordance and overall PCC (total MPCC) during the medical encounter. It should be noted that there were no significant relationships between gender and Component 3 scores, perhaps reflecting the lower reliability for that subscale. In other analyses of these data, 15 we have generally failed to find correlations with Component 3 scores, suggesting that it might not be as viable a measure as the two other components. Furthermore, closer examination of the criteria for scoring Component 3 suggests that physicians are rewarded with higher scores if they provide explanations and solicit questions, even if they do not use other communication behaviors that might promote partnership, such as offering involvement in decision making. It may be that gender is not a key determinant of those particular Component 3 behaviors. There are a number of study limitations that should be noted. The selected sample of physicians willing to be enrolled in a study that audiotaped their encounters might not reflect average physicians in their practice style. Specifically, physicians enrolled in a study involving monitoring of their communication may have above average interpersonal skills, blunting gender differences. Moreover, physicians behavior with a new patient may not predict their practice style with established patients, where the relationship has developed over time. Despite the advantages to using SPs, there are disadvantages: the extent to which such encounters represent normal real patient encounters is uncertain. There were only five SPs (two male and three female) in the study, limiting the generalizability of results. The use of standardized case scripts may have minimized gender differences presented by the SPs and, in turn, patient gender influences on physicians. Despite this possibility, the most robust effects observed were for SP gender. We also found that physicians detected some of the SP

6 544 BERTAKIS ET AL. encounters. The literature on SPs and their detection, however, suggests that physicians do not behave differently in detected encounters. 37 There are two measurement concerns. The lack of interrater reliability in coding Component 3 of the MPCC may have contributed to our failure to observed gender-related effects. Second, given that we were concerned with the influence of gender on communication, it is noteworthy that both coders were female. As the coding system depends on coders listening to audiotapes, there may have been some bias in their coding depending on the sex of the speaker. Finally, while the effects observed for patient gender were robust, other effects, though statistically significant, were small. Thus, the inconsistent findings may reflect random variation. In conclusion, we found that female patients had visits with their physicians characterized by greater measures of PCC. There were no significant differences in summary MPCC scores for the encounters of female vs. male physicians or for gender-concordant compared to discordant physician-patient dyads. These findings add further evidence that patient gender can affect the interactions between physicians and patients, although the inconsistent findings for different components of PCC suggest that unmeasured elements other than gender (e.g., personality, social expectations) may also play an important role and that assumptions based on demographic factors alone are not sufficient to account for many of the observed dynamics of communication in unique pairings of patients and physicians. 38 More research is needed to understand why male patients are less likely to have medical encounters in which their physicians employ a patient-centered practice style. To improve PCC in all possible patientphysician gender pairings, it will be important to identify underlying mutable patient, physician, and contextual factors that underlie observed differences in communication attributed to gender. Disclosure Statement No competing financial interests exist. References 1. Kellerman R, Kirk L. Principles of the patient-centered medical home. Am Fam Physician 2007;76: Stewart M. Towards a global definition of patient-centered care. BMJ 2001;233: Epstein RM, Franks P, Fiscella K, et al. Measuring patientcentered communication in patient-physician consultations: Theoretical and practical issues. Soc Sci Med 2005;61: Mead N, Bower P. Patient-centeredness: A conceptual framework and review of the empirical literature. Soc Sci Med 2000;51: Epstein RM, Street RL Jr. Patient-centered communication in cancer care: Promoting healing and reducing suffering. National Cancer Institute, NIH Publication No Bethesda, MD, Stewart M, Brown JB, Donner A, et al. The impact of patientcentered care on outcomes. J Fam Pract 2000;49: Swenson SL, Buell S, Zetter P, White M, Ruston DC, Lo B. Patient-centered communication: Do patients really prefer it? J Gen Intern Med 2004;19: Krupat E, Bell RA, Kravitz RL, Thom D, Azari R. When physicians and patients think alike: Patient-centered beliefs and their impact on satisfaction and trust. J Fam Pract 2001;50: Roter DL, Stewart M, Putnam SM, Lipkin M, Stiles W, Inui TS. Communication patterns of primary care physicians. JAMA 1997;277: Bertakis KD, Callahan EJ, Helms LJ, Azari R., Robbins JA, Miller J. Physician practice styles and patient outcomes. Difference between family practice and general internal medicine. Med Care 1998;36: Stewart M. Effective physician-patient communication and health outcomes: A review. Can Med Assoc J 1995;152: Mead N, Bower P. Patient-centered consultations and outcomes in primary care: A review of the literature. Patient Educ Couns 2002;48: Franks, Jerant AF, Fiscella K, Shields CG, Tancredi DJ, Epstein RM. Studying physician effects on patient outcomes: Physician interactional style and performance on quality of care indicators. Soc Sci Med 2006;62: Bertakis KD, Azari R, Callahan EJ, Helms LJ, Robbins JA. The impact of physician practice styles on medical charges. J Fam Pract 1999;48: Epstein RM, Shields CG, Meldrum SC, et al. Patient-centered communication and diagnosis testing. Ann Fam Med 2005;3: Bertakis KD, Helms LJ., Callahan EJ, Azari R, Robbins JA. The influence of gender on physician practice style. Med Care 1995;33: Bertakis KD, Franks P, Azari R. Effects of physician gender on patient satisfaction. J Am Med Womens Assoc 2003;58: Roter DL, Hall JA. Physician gender and patient-centered communication: A critical review of the empirical research. Annu Rev Public Health 2004;25: Roter DL, Hall JA, Aoki Y. Physician gender effects in medical communication: A meta-analytic review. JAMA 2002;288: Hall JA, Roter DL. Patient gender and communication with physicians: Results of a community-based study. Womens Health 1995;1: Kaplan SH, Gandek B, Greenfield S, Rogers W, Ware JE. Patient and visit characteristics related to physicians participatory decision-making style. Results from the Medical Outcomes Study. Med Care 1995;33: Bertakis KD, Azari R. Patient gender and physician practice style. J Womens Health 2007;16: Weisman CS, Teitelbaum MA. Physician gender and the physician-patient relationship: Recent evidence and relevant questions. Soc Sci Med 1985;20: Garcia JA, Paterniti DA, Romano PS, Kravitz RL. Patient preferences for physician characteristics in university-based primary care clinics. Ethn Dis 2003;13: Bonds DE, Foley KL, Dugan E, Hall MA, Extrom P. An exploration of patients trust in physicians in training. J Health Care Poor Underserved 2004;15: Hall JA, Irish JT, Roter DL, Ehrlich CM, Miller LH. Gender in medical encounters: An analysis of physician and patient communication in primary care setting. Health Psychol 1994;13: Franks P, Bertakis KD. Physician gender, patient gender, and primary care. J Womens Health 2003;12:73 80.

7 PATIENT-CENTERED COMMUNICATION AND GENDER Kroenkek, Spitzer RL, degruy FV, et al. Multisomatoform disorder. An alternative to undifferentiated somatoform disorder for the somatizing patient in primary care. Arch Gen Psychiatry 1998;55: Brown J, Stewart M, Ryan BL. Assessing communication between patients and physicians: The Measure of Patient- Centered Communication (MPCC) working paper series (2nd ed). London, Ontario, Canada: Thames Valley Family Practice Research Unit and Centre for Studies in Family Medicine, Snijders T, Bosker R. Multilevel analysis. An introduction to basic and advanced multilevel modeling. London: Sage Publications, Cohen J. A power primer. Psychol Bull 1992;112: Clogg CC, Petkove E, Hariton A. Statistical methods for comparing regression coefficients between models. Am J Sociol 1995;100: Kelly JM. Sex preference in patient selection of a family physician. J Fam Pract 1980;11: Graffy J. Patient care choice in a practice with men and women general practitioners. Br J Gen Pract 1990;40: Kerssens JJ, Bensing JM, Andela MG. Patient preferences for genders of health professionals. Soc Sci Med 1997;44: Street RL Jr, Gordon HS, Ward MM, Krupat E, Kravitz RL. Patient participation in medical consultations: Why some patients are more involved than others. Med Care 2005; 43: Franz CE, Epstein R, Miller KN, et al. Caught in the act? Prevalence, predictions, and consequences of physician detection of unannounced standardized patients. Health Serv Res 2006;41: Duberstein P, Meldrum S, Fiscella K, Shields CG, Epstein RM. Influences on patients ratings of physicians: Physicians demographics and personality. Patient Educa Couns 2007; 65: Address reprint requests to: Klea D. Bertakis, M.D. Professor and Chair Department of Family and Community Medicine Director, Center for Healthcare Policy and Research University of California, Davis 4860 Y Street, Suite 2300 Sacramento, CA kdbertakis@ucdavis.edu

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